Sherrill House
135 South Huntington Avenue, Boston, MA 02130 · Non profit - Corporation · 196 certified beds · (617) 365-6024 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $35,860 in federal fines (most recent 2026-04-10)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.3% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.2% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.2% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 15.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.6% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.8% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.1% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.9% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.1% | 21.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.1% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.1% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 34.5% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.6% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.58 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.59 | 1.50 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
64.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 566 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 326 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.4%CMS range 59.3–67.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 8.5–12.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.3%CMS range 3.6–7.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 196 beds and averages 162.5 residents a day — about 83% occupied, or roughly 34 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 3.76 on weekdays — 9% thinner on weekends. RN hours go from 0.71 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2026-04-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing a.) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's recommendations and b.) accurately implement a wound intervention of an air mattress for four Residents (#152, #32 , #4, and #5) out of a total sample of 33 residents. 1.For Resident #152, the facility failed to prevent an existing ankle wound that was present on admission to the facility from worsening from a Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed) pressure ulcer to a Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle) pressure ulcer by not assessing and monitoring the wound and not implementing physician orders for wound treatment.2.For Resident #32, the facility failed to (a) ensure treatment orders were transcribed and implemented per the Wound Nurse Practitioner's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2026-04-10 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice was provided for one Resident (#4) out of a total sample of 33 residents. Specifically, the facility failed to provide interventions for pain management during wound care treatment, resulting in the Resident experiencing pain during the wound care.Findings include: Review of the facility policy titled 'Pain-Clinical Protocol' dated March 2018, indicated the following but not limited to:-The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain, for example degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes.-The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-10 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure that services provided met professional standards for 3 Residents (#146, #42, and #134), out of 33 total sampled residents. Specifically,1.) For Resident #146, the facility failed to notify the provider and obtain and implement Bumex (a diuretic medication) for a weight gain as ordered by the physician.2.) For Resident #42, the facility failed to (2a.) implement a functioning air mattress physician's order, (2b.) complete a wound treatment and dressing documentation in the Treatment Administration Record (TAR).3.) For Resident #134, the facility failed to ensure daily weights were obtained according to the physician's orders. Findings include: 1.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-10 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements in two out of four medication carts observed. Specifically,1.) The facility failed to ensure medications with shortened expiry dates were dated once opened, according to manufacturer's guidelines.2.) The facility failed to ensure medications were stored in the original, labeled containers. Findings include:Review of the facility policy titled 'Medication Storage', revised April 2019, indicated:- Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.- Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.- Schedule II-V controlled medications are stored in a separately locked, permanently affixed compartments. 1a.) On 4/7/26 at 12:50 P.M., the surveyor and Nurse #2 observed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the the facility failed to notify the physician of a significant change in the resident's physical status for two Residents (#152 and #146), out of 33 total sampled residents. Specifically,1. For Resident #152, the facility failed to notify the provider of an admission with a right ankle pressure injury resulting in delayed treatment and monitoring of the Resident, deterioration of the wound and management of worsening wound condition. 2. For Resident #146, the facility failed to notify the provider of need to implement Bumex (a diuretic medication) for weight gain, which could potentially indicate the clinical complication of fluid overload. Findings include: 1.) Review of the facility policy titled 'Change in a Resident's Condition or Status', revised May 2017, indicated: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. -The nurse will notify the resident's Attending Physician or physician on call when there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-10 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure that, within 48 hours of admission, nursing developed and implemented baseline care plan with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs for one Resident (#152), out of a sample of 33 Residents. Specifically, the facility failed to initiate a baseline care plan to address a right ankle Stage 2 (partial-thickness skin loss- shallow open ulcer with a red-pink wound bed, or an intact/ruptured serum-filled blister) pressure injury resulting in the development of a right ankle Stage 4 (full-thickness tissue loss- exposed bone, tendon, or muscle, often with undermining and tunnelling) pressure injury. Findings include: Review of the facility's policy titled, Care Plans-Baseline, undated, indicated:-A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.-The interdisciplinary team will review the healthcare practitioner's orders (dietary, medications, routine treatments)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to identify and implement interventions for a significant weight loss for one Resident (#141) out of a total sample of 33 residents. Findings include:Review of the policy titled, Weighing and Measuring the Resident, dated March 2011, indicated the following:-Report significant weight loss/gain to the nurse supervisor. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe. -Notify the Nurse Supervisor if the resident refuses the procedure. -Report the information in accordance with the facility policy and professional standards of practice. Resident #141 was admitted to the facility in January 2024 with diagnoses including Alzheimer's Disease, leukemia and dementia. Review of Resident #141's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to accurately document in the medical record for one Resident (#32) out of a total sample of 33 residents. Specifically, for Resident #32, the nurses inaccurately documented checking air mattress settings according to the Resident's weight per the physician's order. Findings include:Review of the facility policy titled 'Charting and Documentation', dated July 2017, indicated the following:-Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #32 was admitted to the facility in January 2023 with diagnoses including Alzheimer's disease, stroke, and functional quadriplegia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/26, indicated that Resident #32 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, and required assistance with activities of daily living including bed mobility. The MDS further indicated that Resident #32 had a pressure-reducing device for bed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Residents (#4) out of a total sample of 33 Residents. Specifically,1.For Resident #4 the facility failed to implement hand hygiene during a wound dressing treatment.2.The facility failed to adhere to contact precautions for Resident #4.Findings include:Review of facility policy titled 'Handwashing/Hand Hygiene', dated August 2019, indicated the following:-All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.-The use of gloves does not replace hand washing /hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of facility policy titled 'Isolation- Categories of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-24 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals and outcomes, that addressed his/her overall immediate care needs. Findings include: Review of the Facility's Policy titled Care Plans - Baseline, dated as last revised 12/2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The Policy indicated that the Interdisciplinary Team (IDT) will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: -Initial goals based on admission orders; -Physician Orders; -Dietary Orders; -Therapy Services; -Social Services; and -Pre-admission Screening and Resident Review (PASRR)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-07 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was alert, oriented and made his/her own health care decisions, the Facility failed to ensure that he/she was fully informed in advance and given information including the risk and benefits of psychotropic medications prior to their use, when Resident #1 was administered nine (9) doses of an antipsychotic medication by nursing, before obtaining his/her consent to administer the medication. Findings include: Review of the Facility Policy titled, Resident Rights, undated, indicated that residents have the right to a dignified existence and to communicate with individuals and representatives of choice and the Facility will protect and promote your rights. The Policy further indicated that all residents have the right to be fully informed of their total health status in an understandable manner. Resident #1 was admitted to the Facility in February 2025 diagnoses included Respiratory Syncytial Virus (RSV, a virus that infects the lungs and respiratory tract) with pneumonia, new onset of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-07 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for three of three sampled residents, (Resident #1, #2, and #3), the facility failed to ensure that upon admission, that nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs. Findings include: Review of the Facility Policy titled Baseline Care Plans, dated as last revised 12/2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The Policy indicated that the Interdisciplinary Team (IDT) will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to; -Initial goals based on admission orders; -Physician Orders; -Dietary Orders; -Therapy Services; -Social Services; and -Pre-admission Screening and Resident Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-04-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had been maintained on oxygen via nasal cannula while at the Hospital, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when despite Resident #1's continued need for oxygen, there was no physician order obtained for administration. Findings include: Review of the Facility Policy titled Medication and Treatment Orders, dated as [NAME] revised 07/2016, indicated that all medication and treatment orders will be consistent with principles of safe effective order writing and shall only be administered upon the written order of a person duly licensed and authorized to prescribe such medications and treatments in this state. Review of the Facility Policy titled Oxygen Administration, dated as last revised 10/2010, indicated to first verify that there is a physician's order in place. Resident #1 was admitted to the Facility in February 2025, diagnoses included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who upon admission, had Orthopedic recommendations for nursing to monitor his/her left wrist and cast, the Facility failed to ensure they maintained a complete and accurate medical record, when the Orthopedic recommendations were not transcribed by nursing onto his/her Treatment Administration Record (TAR), and therefore was no nursing documentation on the TAR to support nursing monitored Resident #1's left wrist/cast. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as last revised April 2008, indicated the following: -all services provided to the resident to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record -all observations, medications administered, services performed, etc., must be documented in the resident's clinical records Resident #1 was admitted to the Facility in February 2025, diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 10/29/24, after Facility Administration was made aware of an allegation of physical abuse, that they reported the allegation to the Department of Public Health (DPH) within two hours as required, and was not reported to the DPH until 12/06/24 (more than a month after Administration was made aware of the allegation). Findings include: Review of the Facility Policy titled Abuse Prohibition, dated as revised 12/21/23, indicated that all alleged violations of Federal and State laws which involve mistreatment, neglect, abuse, injuries of unknown source, exploitation, and misappropriation of resident property are reported immediately to the Executive Director of the Facility. Further review of the Policy indicated that such violations will also be reported to State Agencies in accordance with existing State law. Review of the Report submitted by the Facility via the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 10/29/24, after being made aware of an allegation that he/she had been physically abused by a staff member, they obtained and maintained evidence that a thorough investigation into the allegation had been completed and that a summary of their investigation findings was submitted to the Department of Public Health within five days, as required. Findings include: Review of the Facility's Policy titled, Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal or State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriation of Resident's Property, Exploitation, Adverse Event, or Retaliation, dated as revised 12/21/23, indicated the following: -The investigation shall include interview of associates, visitors, or residents who may have knowledge of the alleged incident. Factual information should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-16 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a dignified experience for the residents of the facility by 1) failing to provide a dignified dining experience for the residents on the first floor unit, 2) ensuring a staff member was not on the phone while providing care for one Resident (#129) and 3) ensuring staff members were not storing person items in the room of one Resident (#38), out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Quality of Life - Dignity, dated 2001, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. -Residents should be treated with dignity and respect at all times. -Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or needs. Review of the facility's Resident Rights policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated food, that staff did not store personal food with resident food and ingredients, that dented cans were not accepted into storage/circulation and that staff did not directly handle ready-to-eat food with contaminated gloves. Findings include: Review of the facility's undated policy titled Food Storage indicated, but was not limited to, the following: - Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. - All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of the foods. o Old stock is always used first (first in - first out method). o Supervise the person designated to put stock away to make sure it is rotated properly. o Food must be dated as it is placed on the shelves o Date marking to indicate the date or day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that one Resident (#144) did not self-administer medications out of a total sample of 34 residents. Specifically, Resident #144 was observed with a card of pills left at bedside for self-administration without being assessed for self- administration. Findings include: Review of the facility policy titled 'Self-Administration of Drugs' dated August 2006, indicated the following but not limited to: -Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering. -If the staff determine that a resident a resident cannot safely self-administer medications, the nursing staff will administer the resident's medication. Review of facility policy titled 'Storage of Medications'…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure one Resident's (#150) personal care choices were honored, out of a total sample of 34 residents. Specifically, the facility failed to provide showers for Resident #150 per his/her request and preference. Findings include: Review of the facility policy titled 'Quality of Life - Self Determination and Participation', revised October 2009, indicated: - Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. - Each resident shall be allowed to choose activities, schedules, and health care that are consistent with his or her interests, assessments, and plans of care, including: Personal care needs, such as bathing methods. Resident #150 was admitted to the facility in November 2023 with diagnoses including heart failure and bilateral lower extremity lymphedema (a chronic condition that causes swelling in the body's soft tissue). Review of the most recent Minimum Data Set (MDS) assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for one Resident (#71) out of a total sample of 34 residents. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #71 was admitted to the facility in November 2021 with diagnoses including dementia. Review of Resident #71's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 3 out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for two Residents (#83 and #101) out of a total sample of 34 residents. Specifically, the facility failed to provide assistance with self-feeding tasks during mealtimes. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated March 2018, indicated the following: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL's. -Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks). -If…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for two Residents (#103 and #88), out of a total sample of 34 Residents. Specifically, Residents #103 and #88 the facility failed to ensure nursing consistently set his/her oxygen flow rate as ordered by the physician. Findings include: Review of the facility policy, titled Oxygen Administration, revised March 2004, indicated, but was not limited to, the following: - Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. - Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: o Vital signs 1). Resident #103 was admitted to the facility in January 2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #103…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations record review and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#364) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to.) out of a total sample of 34 residents. Specifically, the facility failed to ensure clamps and pressure dressings were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include Review of the facility policy titled 'Hemodialysis Access Care' dated September 2010, indicated the following but not limited to: -If there is major bleeding from site (post dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1.) The facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in two out of four medication carts observed. 2.) The facility failed to properly secure medication carts on two of four units. Findings include: Review of the facility policy titled 'Storage of Medications', revised April 2007, indicated: - The facility shall store all drugs and biological in a safe, secure, and orderly manner. - Compartments containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 1a.) On 1/15/25 at 8:28 A.M., the surveyor and Nurse #3 observed the following in the third floor team two medication cart: - One bottle of pro-stat (liquid protein), open and undated.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to provide a palatable meal to the residents on the first floor unit. Findings include: On 1/14/25 at 8:34 A.M., the surveyor observed a pureed meal on a resident's meal tray. The resident was eating eggs and the other food was indiscernible and was shaped in a long brown log form. The resident did not consume the food on the tray. During the Resident Group Interview on 1/15/25 at 1:30 P.M., all participants reported that meals are served cold and sometimes unpalatable. On 1/16/25 at 9:08 A.M., a test tray was completed on the first floor unit with the following findings: -juice was 50 degrees Fahrenheit and tastes cold -oatmeal was 130 degrees Fahrenheit, was bland with a gummy texture and was warm not hot -pureed sausage was 118 degrees Fahrenheit and tasted luke warm, not hot. The sausage was shaped oddly into a brown, long log form, had a gummy consistency and tasted bland. -french toast was 110 degrees Fahrenheit and was luke warm, not hot. The french toast had a slimey layer on the top and has a gummy consistency.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adhere to infection control standards of practice for one Resident (#23) out of a total sample of 34 residents. Specifically, for Resident #23 the facility failed to appropriately follow Enhanced Barrier Precautions (EBP: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other Residents within the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions dated March 2024, indicated the following but not limited to: -EBP are indicated for residents with any of the following: Indwelling medical devices including central lines, urinary catheters, feeding tubes, and tracheostomies. -For residents for whom EBP are indicated, EBP is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-25 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to adequately secure medications. Specifically: 1) For Resident #2 the facility failed to ensure his/her medications were secured and not left at his/her bedside. 2) The facility failed to ensure staff secured medication carts on two of four nursing units. 3) The facility ensured medications were not left unattended on the medication carts and expired medications were not available for administration. Findings include: Review of the facility's Storage of Medications policy, dated as revised November 2020 indicated: *Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. *Schedule II- V controlled medications (narcotics, stimulants and depressant drugs) are are stored in seperately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. Review of the facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to investigate an allegation of potential abuse for 1 Resident (#232) out of a total sample of 32 residents. Findings include: Resident #232 was admitted in 01/2024 with diagnoses including bipolar disorder and attention-deficit disorder. Review of the clinical record indicated that Resident #232 is able to make his/her needs known. Review of the facility policy titled Policies and Procedures Regarding Investigation and Reporting of Alleged Violations of Federal or State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, Exploitation, Adverse Event or Retaliation, dated 3/21/17, indicates the following: - Reporting of suspected alleged violations will be done by all staff, contracted agents, volunteers, families and residents. Incidents of alleged violations shall be reviewed by the facility's Quality Assessment and Assurance Committee for detection of patterns or trends. - The Executive Director and Director of Nursing Services shall identify, intervene and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to administer medications per the physicians order for one Resident (#2) out of a total of 32 sampled Residents. Findings include: Review of the facility's Medication Administration Policy, dated as revised April 2010 indicated: *Medications must be administered in accordance with the orders, including any required time frame. Resident #2 was admitted to the facility in June 2021 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dependence on renal dialysis and epilepsy. On 1/23/24 at 8:20 A.M., the surveyor observed a medication cup on Resident #2's overbed table. The Medication cup contained five pills. Resident #2 was not present as he/she was at his scheduled dialysis appointment. On 1/23/24 at 9:07 A.M., the surveyor observed the medication cup with five pills was still present on Resident #2's overbed table. On 1/23/24 at 9:20 A.M., the surveyor and the Director of Nursing (DON) observed the medication cup with five tablets on Resident #2's overbed table. The DON removed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the formula from an enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach), was infused as ordered for one Resident (#89) out of a total of 32 sampled Residents. Findings include: Resident #89 was admitted to the facility in March 2022 with diagnoses including Parkinson's and dysphagia. Review of Resident #89's most recent Minimum Data Set Assessment indicated he/she scored 3 out of a possible 15 on the Brief Interview for Mental Status Exam, which indicates he/she is severely cognitively impaired. The MDS also indicated that Resident #89 receives nutrition through an enternal feeding (TF) and is dependent on staff for bathing and dressing. On 1/23/24 at 7:49 A.M., the surveyor observed Resident #89 laying in bed. Resident #89 appeared thin and frail. Review of Resident #89's weights indicated the following: 10/2/23: 124.9 lbs (pounds) 11/1/23: 120 lbs 12/1/23: 116 lbs 1/2/24: 115 lbs (a significant loss of 7.5% of his/her total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$35,860 in federal fines across 1 penalty.
- $35,860 — penalty dated 2026-04-10
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DEDHAM INSTITUTION FOR SAVINGS | Organization | 5% OR GREATER SECURITY INTEREST | since 05/20/2024 |
| ALLEN, MORGAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| BENKA, RICHARD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| CLARK, GRACE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| FLANAGAN, JANE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| HADDAD, PAULINE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| LEDERMAN, ISAAC | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| MORROW, MARK | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| PIERSON, ALLENE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| STAPLETON, PATRICK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 01/01/2025 |
| STEUL, WILLIAM | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| WHITFIELD, CHERYL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| ZINTI, PAUL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2025 |
| BAUMAN, BARBARA | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 01/01/2025 |
| FISHER, LISTO | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 01/01/2025 |
| KENNEDY, THOMAS | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 01/01/2025 |
| KIRCHNER, DAVID | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 01/01/2025 |
| SEE, FREDERICA | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 01/01/2025 |
| ALLEN, BETHANY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/06/2022 |
| ALTENWEG, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/21/2022 |
| BEGLEY, LORENE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/28/2013 |
| FORMAN, EVGENIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2009 |
| FUMIA, ADAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/12/2002 |
| GILL-LEE, ANGELLA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/28/2022 |
| LOPES, LEAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/21/2005 |
| MCGRATH, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/01/1995 |
| MINIELLO, ALESSIO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/18/2022 |
| VENTURA, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/27/2023 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | since 01/01/1985 |
| SANTOS, JOAO | Individual | ADP OF THE SNF | since 01/31/2022 |
CMS files one row per role, so the 57 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225201. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.